Elsevier

The Lancet Oncology

Volume 22, Issue 2, February 2021, Pages 173-181
The Lancet Oncology

Articles
Evidence-based benchmarks for use of cancer surgery in high-income countries: a population-based analysis

https://doi.org/10.1016/S1470-2045(20)30589-1Get rights and content

Summary

Background

Estimating a population-level benchmark rate for use of surgery in the management of cancer helps to identify treatment gaps, estimate the survival impact of such gaps, and benchmark the workforce and other resources, including budgets, required to meet service needs. A population-based benchmark for use of surgery in high-income settings to inform policy makers and service provision has not been developed but was recommended by the Lancet Oncology Commission on Global Cancer Surgery. We aimed to develop and validate a cancer surgery benchmarking model.

Methods

We examined the latest clinical guidelines from high-income countries (Australia, the UK, the EU, the USA, and Canada) and mapped surgical treatment pathways for 30 malignant cancer sites (19 individual sites and 11 grouped as other cancers) that were notifiable in Australia in 2014, broadly reflecting contemporary high-income models of care. The optimal use of surgery was considered as an indication for surgery where surgery is the treatment of choice for a given clinical scenario. Population-based epidemiological data, such as cancer stage, tumour characteristics, and fitness for surgery, were derived from Australia and other similar high-income settings for 2017. The probabilities across the clinical pathways of each cancer were multiplied and added together to estimate the population-level benchmark rates of cancer surgery, and further validated with the comparisons of observed rates of cancer surgery in the South Western Sydney Local Health District in 2006–12. Univariable and multivariable sensitivity analyses were done to explore uncertainty around model inputs, with mean (95% CI) benchmark surgery rates estimated on the basis of 10 000 Monte Carlo simulations.

Findings

Surgical treatment was indicated in 58% (95% CI 57–59) of newly diagnosed patients with cancer in Australia in 2014 at least once during the course of their treatment, but varied by site from 23% (17–27) for prostate cancer to 99% (96–99) for testicular cancer. Observed cancer surgery rates in South Western Sydney were comparable to the benchmarks for most cancers, but were higher for some cancers, such as prostate (absolute increase of 29%) and lower for others, such as lung (−14%).

Interpretation

The model provides a new template for high-income and emerging economies to rationally plan and assess their cancer surgery provision. There are differences in modelled versus observed surgery rates for some cancers, requiring more in-depth analysis of the observed differences.

Funding

University of New South Wales Scientia Scholarship, UK Research and Innovation-Global Challenges Research Fund.

Introduction

Surgery has a long history in the management of cancer,1, 2 with applications in diagnosis, cure, palliation, and reconstruction. Many factors influence the use of surgery for patients with cancer at each treatment stage and setting,3, 4 including patient-related factors such as age, comorbidities, and preference;5, 6 disease-related factors such as stage;7 and health system-related factors such as availability and access to surgical treatment.8, 9

The rate at which surgery is used for treating cancer varies widely across different geographical regions of the world,8 as well as between different locations within the same country.10 In the absence of an empirically estimated ideal baseline rate of cancer surgery, this variability makes it difficult for health policy makers to decide whether the population-level use of cancer-directed surgery is appropriate and accordingly plan services and allocate economic resources. Population-based benchmark rates will help to determine the demand for cancer surgery at the population level and to plan cancer surgical services to address the needs of the population of patients with cancer in the future. The benchmark rates could be used for the planning and evaluation of cancer services more broadly, to inform rational decision making in both high-income and resource-constrained settings.

The benchmark use rate for any cancer treatment modality is defined as the proportion of new cases of registered cancer that should receive the given treatment at least once at some time during the course of the illness if evidence-based guidelines were followed and the patient is fit enough to undergo treatment. Benchmark rates for radiotherapy and chemotherapy have been estimated before, using evidence-based methods.11, 12, 13 The models of optimal use of radiotherapy in Australia have been adapted to assess the demand for radiotherapy in four European countries by varying the relative frequency of tumour types and the stage at diagnosis for each country.14 The radiotherapy model has been used by the Global Task Force on Radiotherapy for Cancer Control to estimate the future burden of cancer requiring radiotherapy globally and to demonstrate the international shortfall in access to radiotherapy.14

Research in context

Evidence before this study

We searched PubMed, Embase, MEDLINE, and Google Scholar for articles published from inception up to Sept 1, 2019, using an array of search terms including “benchmarking”, “surgical utilization”, “surgical demand”, and “optimal utilization”, with no language restrictions, and no other empirical work on benchmarking use of cancer surgery was found. Similar benchmarking has been previously done for chemotherapy and radiotherapy, and the models have been applied to improve service provision.

Added value of this study

The population-level benchmark for use of cancer surgery in high-income settings is currently unknown. We therefore adapted the work on chemotherapy and radiotherapy use to produce, to the best of our knowledge, the first guideline-based empirical estimate of the proportion of patients with an indication for surgery anytime during the treatment of their cancer. Demand estimates and resource predictions have previously been based on real-world practice and therefore influenced by many supply-side limitations. Our estimate of the benchmark for the use of cancer surgery provides a superior alternative for planning future cancer surgical services. The derived benchmarks can be compared with observed surgery rates at a population level to measure variations in the provision of cancer surgery and to plan for future requirements.

Implications of all the available evidence

This model and the overall evidence produced would generate a framework for estimating current and future demand for cancer surgical services, as well as to plan for future cancer surgical services based on evidence.

Benchmark surgery use has been estimated for cervical cancer15 and breast cancer16 in isolation, but an overall benchmark rate for cancer surgery has not been reported. Cancer surgical demand has been estimated crudely, based on data of observed surgery rates.8 However, surgical demand based on the latest evidence for its indications and population characteristics has not been previously benchmarked.

The aim of this study was to develop an evidence-based benchmark rate for cancer surgery use, validated in a high-income setting using Australian data.

Section snippets

Study population and data sources

The study population for our model included all cases of malignant cancer that were notifiable in Australia and thus registered in Australian cancer registries for the year 2014, the most recent year for which incidence data were available. The list of notifiable cancers is available in the appendix (pp 3–4). When developing the model, epidemiological data (eg, cancer type, incidence, and stage) derived from Australian national or state-wide surveys and databases were given priority over other

Results

The overall benchmark surgery rate predicted by our model for Australia was 58% (95% CI 57–59), meaning that surgery is indicated in 58% of newly diagnosed patients with cancer in Australia at least once during the course of their illness. By cancer site, this percentage varied from 22% (95% CI 17–27) in prostate cancer to 99% (96–99) in testicular cancer (table 1). When compared with observed surgery rates from the SWSCCR, the maximum positive deviation from the benchmark was observed for

Discussion

We estimated that, in the Australian population, 58% (95% CI 57–59) of all patients with cancer in 2017 had an indication for surgery at least once during their treatment. The benchmark varied between 23% and 99% for individual cancer sites. The observed cancer surgery rates from SWSCCR differed from the model-predicted benchmark rates for some cancers, but for most, there was minimal difference from the benchmark.

The Lancet Oncology Commission on global cancer surgery has previously estimated

Data sharing

This study represents a modelling exercise to evaluate population-based cancer surgical utilisation, demand, and workforce requirements. All relevant descriptions of variables, data inputs, and the respective values have been included either in the main text of the Article or in the appendix. The authors do not hold exclusive rights to data, as all the data used in the study are either publicly available or can only be obtained via respective authorities handling relevant clinical or

References (29)

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